A resident with DM received 50 units of Novolog instead of the ordered 50 units of Tresiba after an RN failed to verify the insulin type before administration. The MAR, progress notes, incident report, and staff interviews confirmed the medication error, and the resident was monitored for hypoglycemia afterward.
A nurse failed to verify a resident’s identity before preparing meds and allegedly gave insulin intended for another resident, along with attempting to administer two oral meds not ordered for the resident. The resident, who was cognitively intact and had no insulin order, reported that the nurse checked a BG, asked where to inject the insulin, and then attempted to give Keppra and a sodium tablet before realizing the identity mix-up. The nurse acknowledged relying on a first name heard in the room and using the other resident’s EMR and orders.
A resident received another resident’s meds after an agency RN gave the roommate’s insulin, antipsychotics, antidiabetic, benzodiazepine, anticonvulsant, antidepressants, laxative, and eye drops to the wrong person, even though the resident had already received scheduled AM meds from an MA. The resident became lethargic and unresponsive with hypoglycemia, low BP, and bradycardia, required Glucagon and EMS transfer, and was admitted to the hospital for monitoring.
Significant medication error with intramuscular antibiotic administration: A resident with CKD and a UTI had an order for IM Ertapenem for 5 days, but the MAR did not show one scheduled dose as given. Surveyors found two unopened doses in the med cart, and the RN acknowledged the missed sign-off while the DON could not explain how the ordered doses were administered if doses remained in the cart.
A resident with cardiomyopathy and atrial fibrillation had an order for metoprolol tartrate 25 mg BID to be held only if HR was below 55 bpm and the physician notified. MAR review showed multiple doses were held for HRs above the ordered parameter, and several held doses had no documented HR. An LPN acknowledged the doses were given outside the HR parameters, and the DON could not provide evidence the medication was administered as ordered.
A resident missed 6 doses of a prescribed antibiotic, and the MAR did not show that the provider was notified. The RN acknowledged the missed doses and said they should have been reported, while the Medical Director stated she was unaware of the missed doses and would have extended the antibiotic course if informed. The DON also confirmed the missed doses and expected provider notification for any missed antibiotic dose.
A nurse’s transcription error led to a Farxiga order, intended for one resident, being entered into another resident’s chart, causing that resident—who had diagnoses including edema and hypokalemia—to receive Farxiga 5 mg daily for an extended period before the mistake was discovered. The issue came to light following a community complaint and was confirmed through record review, a Medication Error Form, staff statements, and an interview with the DON, all documenting that the incorrect medication was administered for many days.
A resident with ESRD and gastritis had orders for dialysis and scheduled doses of Auryxia and Pentasa, but MAR review showed repeated missed 8:00 AM doses on dialysis days. The record did not show that the MD was notified, and the ADNS acknowledged Auryxia was not being given at the facility while the dialysis center confirmed it did not administer Pentasa during treatments.
A resident with CHF, afib, moderate cognitive impairment, and low body weight was mistakenly given another resident’s clozapine 150 mg and melatonin 3 mg by a CMT who entered the wrong room and failed to verify identity, contrary to facility policy requiring multiple resident-identification checks. The resident did not receive ordered warfarin and metoprolol during this pass. Subsequently, the resident was found unresponsive with abnormal respirations, tachycardia, and hypoxia, required EMS intervention with suctioning, high-flow oxygen via BVM, and IV emergency cardiac medication, and was admitted to the hospital with altered mental status, profound hypothermia, pleural effusion, and aspiration pneumonia, later transitioning to comfort care and expiring. The DON was unable to show the resident was kept free from significant medication errors, and the Medical Director stated she expected correct medications to be given to the correct resident.
Significant medication errors occurred during antibiotic treatment for a resident with infected bilateral heel wounds. Metronidazole 250 mg was incorrectly transcribed from TID to BID, resulting in 20 doses given instead of the 30 ordered, and metronidazole 500 mg sprinkles were also shorted, with 13 doses administered instead of 14. The Unit Manager acknowledged the transcription and dosing errors, and the DON could not provide evidence the resident was kept free from significant medication errors.
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